MedPix® Patient Chart Case: 3991

History

Age: 65 :: Gender: Male

Patient History

65 y/o WM with a history of CRI, DM, MDS, DVT, Gout, HTN, and a previous CVA who reports that he was awoken from sleep with chest pain. He characterized his chest pain as 10+/10, did not radiate, was worse with movement, and nothing palliated the pain. Under advice by email from his nephrologist, he conducted a 15-20 mile roadmarch carrying a 50-pound rucksack to an extraction site where he was picked up by a Navy Helicopter and flown to civilization. He presented to the walk-in clinic two days later for evaluation. Patient reports a rash of two days prior to the chest pain that was vesicular, spread down the posterior aspect of his right arm, and extremely puritic. He also reports a recent history of 5-10 days of fatigue, subjective fevers, and weight loss (unable to give amount). Patient denies SOB, difficulty breathing, edema, change in bowel habits, dysuria, changes in urination, headaches, but does report a history of intermittent chills with a non-productive cough

Exam

Physical Exam and Laboratory

65 y/o Caucasian male in moderate distress; appears stated age
V: 181/82 87 16 99.1 Wt 86kg
Pulsus paradoxus
CVS: hyperresonant S1 and S1, pericardial rub best heard in forward leaning position
Extrem: bilateral 2+ pitting edema in LE up to mid-calf; equal

ECG: 90, NSR, nml axis, no hypertrophy, no evidence of ischemia, flattening of t-waves in lateral leads, isoelectric PR and ST segments

Cardiac Enzymes: negative
141 105 64
Ca 7.8, Phos 3.7, pt 15.6, ptt 34, INR 1.4, ast 35, alt 26, alk phos 158, tbili 0.4
------------------<78
4.3 26 4.2

11.4 Neut 73, lymph 6, eos 12
13.4>---------<299
34.1